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OLD REPUBLIC INSURANCE COMPANY <br />WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY <br />NOTICE OF CANCELATION TO CERTIFICATE HOLDERS ENDORSEMENT <br />This endorsement modifies the notice of cancelation of insurance provided hereunder by adding the <br />following: <br />A. In the event this policy is canceled for any permissible reason, other than for nonpayment of <br />premium, we shall endeavor to provide advance written notice of cancelation to certificate holders <br />set out in the schedule on file with the Company, after notifying the Insured first named in item 1 <br />of the Information Page of such cancelation. Notice of cancelation to certificate holders may be <br />made by any commercially reasonable means, including mail, electronic mail, facsimile <br />transmission or courier service. <br />B. This advance written notification of a cancelation of coverage is intended as a courtesy only. Our <br />failure to provide such advance written notification will not extend the policy cancelation date, nor <br />negate cancelation of the policy. <br />All other terms and conditions of this policy remain unchanged. <br />WC 99 03 64 (03/11) <br />e R1skM0sagmamtDMsta i <br />A REAEwm&APPRIN®BN - <br />Page 1 of 1 ll <br />Risk Management Analyst <br />